Clinical Governance

Clinical Governance is the framework through which the hospital is accountable for continuous improvements in services and quality creating an environment of clinical excellence. It is a patient-centred approach to care that is accountable in providing a safe, high quality service in an open and questioning environment.

The key components of Clinical Governance are:

- Clear lines of responsibility and accountability for the overall quality of clinical care

- A comprehensive programme of quality improvement activities

- Clear policies aimed at managing risk

A Clinical Governance Committee was formed in the hospital early in 2005. This Committee was established to continuously monitor the quality of services and ensure high standards of care by developing a culture of excellence. The committee meets weekly and members include the Master, Director of Midwifery/Nursing, General/Secretary Manager, Clinical Risk Managers, Clinical Practice Co-ordinator and Quality Manager.

The committee met on 43 occasions during 2012. A total of 2152 incidents were reported to the State Claims Agency and of those that were reported 86 were non clinical up to the end of April. In May 2012 the reporting and processing of non clinical incident forms came under the responsibility of the Health and Safety Officer. This number represents the enormous commitment by the staff of The National Maternity Hospital to continually monitor and improve care.

The Executive Clinical Governance Group was established this year under the auspice of the Master. Membership consists of Consultants from different specialities, Quality Manager, Clinical Risk Managers and Secretary/General Manager. Meetings take place on a monthly basis. Their purpose is to overview Clinical Governance within the hospital.

The Quality, Risk, Health and Safety committee meets on a monthly basis. The purpose of this committee is to operate an integrated process for the management of risk and to monitor the Risk Register.

The Risk Register which is the organisations risk status is maintained at both corporate and local level. The purpose of the Risk Register is to capture risk information from the ‘bottom up’ within each service area. The Risk Register will be a primary tool for risk tracking and analysis. This is to ensure that health, personal and social services are safe and of an acceptable quality. The Committee will report through the Secretary/General Manager to the Executive Management Team and the Board of Governors with the appropriate reporting and linkages to the Clinical Governance Committee.